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FORUMS > EKG CHALLENGE [ REFRESH ]
Thread Title: Early Repolarization?
Created On Mon Jun 02, 2008 8:15 PM


ncmedic309
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Mon Jun 02, 2008 8:15 PM

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Here's another interesting EKG from a recent case:

12-Lead EKG

Just a couple quick notes:

53 year old male with no significant medical history - chest pains for about 2 days. The pain is under his left lower sternum almost midaxillary and is described as an ache. He state's it feels sore to the touch and the pain is reproducible with palpation and movement. He denies any trauma or recent illness. He decided to call EMS after having some numbness and tingling in his right arm. He denies any other associated symptoms.

Vitals:

BP 138/86
HR 40-50
RR 18
Spo2 100% (RA)

What do you think of the EKG? How would you care for this patient?

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jsadin
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Mon Jun 02, 2008 9:52 PM

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From the ST elevations, I'd say anterior MI. The presentation is strange tho'. Why the palpable pain? If it were pericarditis I'd expect global ST elevations and sharper pain. Hmmm. Someone else will have to play.

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arctickat
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Mon Jun 02, 2008 10:32 PM

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Reasons for inverted T waves are numerous and may include ischemia, Heart attack, hyperventilation, Anxiety, certain medications, myocarditis, pulmonary embolus , electrolyte disturbance, Wellens' syndrome, left ventricular hypertrophy, or CNS disorder.

Personally, given the history you've provided I have a suspicion....let's see if my questions can confirm it.

1. Is he a physically fit individual?
2. Any increased temp.?
3. Any change on exertion?



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ncmedic309
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Mon Jun 02, 2008 11:27 PM

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He's in fairly good physical shape but is afebrile and the pain is constant - only changing with palpation and mainly when moving his left arm - so yeah - I guess you could say pain on exertion.

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tadelfio
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Tue Jun 03, 2008 1:13 AM

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Probable pericarditis.

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TomB
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Tue Jun 03, 2008 9:15 AM

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This ECG appears to show a strain pattern from left ventricular hypertrophy.

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Prehospital 12 Lead ECG blog

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arctickat
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Tue Jun 03, 2008 10:30 AM

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I doubt it's pericarditis, you'd see global ST changes, not just in a few leads. my thinking is left side myocarditis. When I'm wondering about pain on exertion I'm thinking strenuous exercise, as TomB mentions.

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Edited: Tue Jun 03, 2008 at 12:59 PM by arctickat

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TomB
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In my mind, pain on palpation or movement of the arm does not qualify as pain on exertion. The former is suggestive of a non-cardiac cause, whereas worsening pain with exertion suggests cardiac ischemia.

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Prehospital 12 Lead ECG blog

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jsadin
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Tue Jun 03, 2008 7:53 PM

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Possibly something encroaching on the LAD? Tumor? Was this sudden onset or gradually getting worse over the past two days?

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roblanious
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Tue Jun 03, 2008 7:59 PM

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I know that V1 and V2 can be commonly elevated a bit but despite his pain appearing non-cardiac, I would still be inclined to be still really consider an anterior MI though focal myocarditis may be a consideration. NC, any fever?

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ncmedic309
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Tue Jun 03, 2008 8:48 PM

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No fever and about a two day onset with the pain...

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AZCEP
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Tue Jun 03, 2008 9:08 PM

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Proximal thoracic aortic aneurysm

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Edited: Tue Jun 03, 2008 at 9:08 PM by AZCEP

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grambograham
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That would be my guess Azcep. The ECG shows some abnormality. No Wellin's sign or signs of pericarditis. The ain being reproduced with pain says that it probably isn't endocarditis. The rhythm itself should not be causing pain. The most likely cause is a possible aneurysm or slow bleed. Either way, stay away from nitro and be cautious with anything which will thin the blood.

No bolus. Start 2 large IVs. Handle pain with fentanyl and don't strain the patient's chest or abdomen by pushing on it. Get to an ER with a cardiothoracic surgeon.

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B9member
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Wed Jun 04, 2008 9:03 PM

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A thoracic aneurysm is definitely a possibility but I am thinking it sounds more like a thoracic aortic dissection with the symptoms listed. I know the classic presentation is a ripping, tearing pain but some patients only present with a milder pain that can be confused with musculoskeletal pain like our guy. With the anterior MI symptoms it is most likely an anterior arch or aortic root dissection.
Any bruits or murmurs on exam?

Treatment: O2, 2 large bore IV's @ TKO unless he becomes hypotensive and pain meds (pretty much what has been suggested). I'd check a BP and pulses in all extremities as well not that any differences will necessarily rule dissection in or out but may give some more clues.

If he becomes any more hypertensive I would want to start some kind of antihypertensive to keep him around the 100 to 130 systolic range (perhaps nipride with a beta blocker first to counteract the reflex tachycardia- he is bradycardic already but hypertension will kill him faster than bradycardia). Most likely these will be started in the ER though. If I was suspecting this diagnosis and also the aortic aneurysm it would probably be advisable to talk to a doc about what treatments to use prehospital.

Not sure where you are coming from with the avoidance of nitro, Grambo? Definitely no blood thinners I agree. (or aspirin).

Anyway just my 2 pennies ; )

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AZCEP
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Wed Jun 04, 2008 11:12 PM

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With the two day presentation, I'd guess that it isn't quite a full dissection yet.

Absolutely agree with careful watch on the blood pressure though. A beta blocker would be quite useful, as might some fentanyl to take the edge off a bit.

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Jedi4Life
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Wed Jun 04, 2008 11:38 PM

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I was thinking along the same lines as AZCEP. (My teacher was just telling us about a similar case where it progressed in the ER.) I was just curious how the loss of blood would show up on the monitor? I've only seen a pt bleed out one time. I was in the monitor room and noticed a sudden spike in HR which was followed a quarter of an hour later by a extreme drop in HR. His t-wave never changed though. They said a tumor ruptured in his right lung causing his lungs to overflow with blood the said the room was covered with blood. Really sucks cause he was a cool guy...

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B9member
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Thu Jun 05, 2008 1:04 AM

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I agree if it was a full dissection we would be calling the coroner. The fact that he is now experiencing numbness and tingling in his right arm means that it is progressing and he is extremely lucky that he is not dead yet. About 30% die in the first 24 hours and 50% die within first 48 hrs with an aortic dissection if left untreated.

Speed and BP control are his best hope. If it starts to progress then we open the fluids up and give a rapid infusion of diesel or Jet A.

Talk about a ticking time bomb!

Did you find out the diagnosis NC?

Blood loss shows up on the monitor by increasing tachycardia, hypotension and a narrowing pulse pressure. You see the sat reading start to fail and decrease as well because of the poor perfusion.

Once they start to drop their HR you are waaay too late. Pretty hard to get them back at that stage. I saw it happen once but it didn't end up changing the outcome because by then they were in full-blown DIC as well.

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grambograham
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Thu Jun 05, 2008 1:29 AM

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The HR clued me in to no nitro. A person in pain with an apparent absence of heart muscle or electrical damage is generally not a good sign. It often indicates a worsening condition. Causing a sudden drop in BP is just as harmful to this person as an increase would be. If we take a bleeding patient and dilate their blood vessles, generally bad things happen and prognosis becomes grim. I'd be cautious with using medications affecting the vasoconstricting response in this case. If the HR were elevated a bit, I wouldn't be as concerned.

Hint number 2 came from reading the 2 day hx of symptoms. Something must have changed to have called 911. Something about the case makes me doubt that the reason 911 was called was because of the arm tingling. I'm guessing the pain increased or perhaps he felt sicker.

With those vitals, you'd expect him to be faking this but the HR and BP tell a different story when added to the 12-lead. This is a pretty sick patient who could drop like a rock if too much change is initiated through meds.

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B9member
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Actually this guy needs his BP controlled and they usually do it with nitrates. Nitroglycerin is not contraindicated in this pt and may prevent the dissection from progressing before we can get him to the hospital.

We want him to be lower on his BP to more like 100-120 systolic. Nitroglycerin will relax the walls of the vessels and decrease the pressure and stress on the tear and hopefully buy more time. He may get a reflex tachycardia from the nitro to increase the HR anyway. The HR is not his major concern. It may be result of the anterior AMI he is having because of where the dissection is interrupting the coronary blood flow. Nipride will eventually be a better choice so you have more control over the BP but I would use nitro to get him to the ER alive.

On the off chance it is just a lateral AMI than the nitro should help there as well. And if it is a dissecting aneurysm it will help for the reasons already stated.

Here's an informative link about aortic aneurysms and dissections.

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roblanious
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Fri Jun 06, 2008 6:55 AM

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This reminds me of a local transfer from an outlying hospital where my wife works part time in the ED to our ED a few years back. The patient was in their ED for a few hours being treated for an ACS until they found he had an aneurysm. He coded enroute via ground ambulance (one of the best in the area, at that). My wife was the one who told me the story and she was very upset over it, especially since the guy was in his late 30s and she remembered talking to him.

Anyway, how are you guys so sure this is an aneurysm?



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B9member
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Fri Jun 06, 2008 5:18 PM

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First of all it may of may not be an aneurysm. You can have a dissecting aneurysm but you can have a dissecting aorta without an aneurym. You really can't tell just by the symptoms without imaging.

Second his age is in the peak incidence group of 50- 65 years old.

It is 3 x more common in men than women.

His symptoms pretty much tell you the location of the tear - aortic arch or aortic root tears are associated with anterior chest pain and mimic anterior AMI because the dissection interrupts the coronary blood flow reflected in his EKG.

Not all patients present with the classic tearing, ripping pain and only have mild pain which is often mistaken for musculoskeletal pain. I would say the movement with the palpation and just movement is enough to increase the pain as you are "jiggling" the aorta so it is adding to the confusion of what is causing the pain exactly.

Even though he has had the pain for 2 days it was probably initially a sudden onset and he has no other significant symptoms.

The fact that he has now developed right limb paresthesia only adds to the diagnosis as it is probably a sign that the tear is progressing and extending into the innominate artery and disrupting blood flow to the right arm.

Did that cover it?

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grambograham
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Sat Jun 07, 2008 2:35 AM

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I'd say you covered the bases nicely B9. You are correct that nipride would be a better option due to the easier BP control. I'm still not a big fan of nitro in aneurysms but as a last resort, I may consider it. Of course, when nitro is initiated, IV is the best route with careful monitoring of HR, BP and LOC as if the aneurysm is well progressed, the ability for this patient to compensate may be next to nothing. He may crump infront of us. Granted a BP of 138 does run a risk of furthering the aneurysm to an unrepairable state. Either way can harm. I'd guess that the aneurysm has dissected and is bleeding due to the increase in pain over the two days. I'd be curious if there is any abdominal pain associated or difficulty breathing.

Is he on medications? The HR, RR, and BP are anomolies. Is he a user of anabolic steroids or amphetamines?

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TomB
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Mon Jun 16, 2008 9:57 PM

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Anything more on this case? What was the computerized interpretation?

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Prehospital 12 Lead ECG blog

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ncmedic309
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Wed Jun 18, 2008 3:58 PM

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Here is the monitor interpretation of the original 12-Lead EKG:

Zoll Interpretation

I ran 8 different 12-Leads during this call - each of them almost identical to the other and each interpretation calling the EKG an Acute MI. The patient was made a code STEMI based on protocol, the EKG findings and the atypical presentation of chest pain. Upon arrival at the ED subsequent 12-Lead EKGs were performed and showed the same findings as the pre-hospital EKG. The cardiologist that reviewed the case in the ED was certain that it was early repolarization that was causing the EKG changes. The cause of the chest pain was undetermined. An ultrasound was performed in the ED and showed good cardiac function without any abnormalities. The patient was not immediately sent to the cath lab and I was not able to follow-up once leaving the ED.

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TomB
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Wed Jun 18, 2008 4:27 PM

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Thanks, ncmedic309! That's extremely helpful.

Technically, ST segment elevation is early repolarization. When it's caused by acute MI, we call it a STEMI. Benign early repolarization (the kind with the fish-hook J point and upwardly concave ST segment) is common, especially amongst males of African descent, but I don't think it's what the cardiologist was referring to in this particular case. Rather, this appears to be a secondary ST/T wave abnormality from left ventricular hypertrophy (a so-called "strain pattern" although the new terminology is repolarization abnormality). With a typical strain pattern, the QRS complex with the deepest S wave (in this case V3) will show the highest ST segment (discordant relationship). In addition, the lateral leads will often show a discordant "pouty lipped" T wave (most obvious here in leads I and aVL, but also visible in leads V5 and V6). Most of the time, the ST segments will be upwardly or downwardly concave, but not always.

I'm surprised the GE-Marquette 12-SL algorithm was fooled by this ECG, although it might have something to do with the small equiphasic QRS complex in lead V2.

Thanks for the follow-up!

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ncmedic309
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Wed Jun 18, 2008 5:34 PM

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I wasn't convinced that the patient was having a STEMI - but went ahead and treated as so mainly due to protocol. The presentation didn't scream infarct to me, nor was I extremely concerned about aortic problems. The EKG was a little more concerning, but I've seen similar strips in the past that were secondary to hypertrophy and conduction delays. After reviewing the strips on scene, repeat strips and the atypical presentation - there was no way that I could justify not making the patient a code STEMI and treating per protocol. We went down that road, he got Aspirin and NTG and only reported slight relief in pain which I believe had nothing to due with the medication administration.

Interesting nonetheless and thanks for the additional information on the EKG and case.

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FORUMS > EKG CHALLENGE [ REFRESH ]

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